The Ultimate Failure

Some Physicians Find the Life They Can't Save Is Their Own

Cover Story - May 2005

By Erin PratherAssociate Editor

An injury disabled his left arm. He had become increasingly moody and introspective. After helping to found the Texas Medical Association in 1853, Anson Jones, MD, believed the state legislature would send him to Washington as a senator. But he received no votes. On Jan. 9, 1858, the last president of the Republic of Texas committed suicide at the Capitol Hotel in Houston.

Although Dr. Jones's life ended more than a century ago, his story is not uncommon today. The October 2000 Southern Medical Journal says the overall physician suicide rate has been between 28 and 40 per 100,000, compared with the overall general population of 12.3 per 100,000. Physicians are more than twice as likely than other people to kill themselves. This is not a new phenomenon. References as far back as 1858 report that physicians in England had a higher suicide rate than the general population. For women physicians, even more alarming numbers have emerged.

Studies show that men are three to five times more likely to kill themselves, but women attempt suicide more often during their lives than men do and they report higher rates of depression. Among physicians, the female suicide rate is lower than that of their male counterparts but consistently higher than that of other women. A December 2004 American Journal of Psychiatry ( AJP ) report says the female physician suicide rate is three to four times that of the general population. The report recommends higher recognition of physicians' suicide risk, particularly among women, and says further studies are needed to explore potential risk factors and possible methods of intervention.

In February, the TMA Committee on Physician Health and Rehabilitation Committee (PHR) held its 12th annual retreat. Titled "Breaking the Silence: Suicide Among Physicians," the retreat was designed for physicians and others interested in learning more about preventing physicians from committing suicide. It was the first PHR event to focus solely on suicide.

One of the speakers, psychiatrist Ashok I. Khushalani, MD, of Humble, called the seminar an important milestone because it brought together parties to discuss suicide, a topic that is usually avoided.

"For me it was gratifying that people were talking about it," he said. "Those who attended heard so many stories of personal tragedies during the seminar -- how individuals were personally touched either by their losses or personal illnesses and how they overcame that. More research needs to be done and the topic of physician suicide discussed in medical settings so the information will be out there. By putting that information in the open, more people will feel less intimidated by the topic."

Established to promote physicians' health and well-being, PHR serves as an important resource for physicians at risk by providing rehabilitation for those who have become impaired for whatever reason. For years, the committee dealt primarily with substance abuse or dependence. Today, disruptive behavior, psychiatric illness, stress management, and boundary issues are also addressed.

Causes of Suicide

Despite research that shows physicians are at a greater risk for suicide than the general public, little is known about the actual number of physician suicides per year. In a 2003 interview conducted by Medscape , Morton Silverman, MD, a member of the American Foundation for Suicide Prevention (AFSP) scientific committee, said the occurrence of mental illness, depression, and suicide in physicians is unknown.

"The best database we have is the AMA death registry, but information is provided to that registry strictly on a voluntary basis, and it often comes from obituaries, which rarely state that the cause of death was suicide."

There is no information available on the number of suicides by Texas physicians.

Issues surrounding physician suicide have numerous dimensions, and the act often stems from complex factors. Two consistent causes are substance abuse disorders (alcohol is the most popular form of self-medication) and/or mental health disorders (often depression).

Herbert Hendin, MD, medical director of AFSP and professor of psychiatry at New York Medical Center, notes that even though depression is frequently a precursor to suicide, physicians often do not recognize the condition in themselves or their patients.

"Physicians generally are more keen and acute in recognizing medical conditions and taking preventative measures," he said. "Smoking is one example. Physician mortality rates from smoking-related cancer decreased because they heeded their own preventative advice. But with suicide, physicians have a disproportionate mortality because they are not diagnosing and getting preventative treatment for depression."

Physicians diagnosed with both a mood disorder and substance abuse are most at risk. More than 90 percent of suicide victims have a significant psychiatric illness at the time of their death, which is often undiagnosed, untreated, or both.

Barriers to Care

The stigmatization surrounding mental illness can be detrimental to the care physicians need. A report in the February 2000 Hospital Physician says physicians are subject to the same influences as the general public, specifically the stigma associated with mental illness. At times, depression is perceived as a weakness or character flaw rather than an involuntary illness. For a physician, who is used to fulfilling a caretaker role, it can be difficult to admit having personal needs and not to perceive those needs as personal weaknesses.

"People have high expectations of their physicians," explains Dr. Khushalani. "They raise them up on a pedestal and have expectations of them that are beyond the human condition. This makes it hard for physicians to admit their own human vulnerabilities and that they actually might need help. To them, their own vulnerability may be seen as weak or somewhat defective and not acceptable. The issue of addiction is one example. There are some in medicine who view addiction as a moral weakness and not as a medically based illness. If that is the belief in the medical community, you can imagine what individuals in the general population must think."

Additionally, the Southern Medical Journal report points out that physicians have the opportunity to self-medicate and often attempt to treat themselves rather than entrust their care to others. More than half of the physicians who commit suicide have self-prescribed medication, and research indicates that 35 percent do not have a regular source of health care.

"Physicians often self-medicate to deal with anxiety or the symptoms of depression," Dr. Hendin said. "But physicians are not the best persons to treat themselves. A high percentage of them do not have a primary care physician, which is unfortunate because there is strong evidence that having one is a major factor in preventive medicine."

Understandably, physicians are often more successful in committing suicide by drug overdose than the average person because of their increased access to drugs and their knowledge of toxicity.

At times, physicians also tend to be treated as "special patients" by their colleagues, thus lowering the quality of their care. One example, presented in the December 2003 AJP , says a psychiatrist gave in to a physician patient's argument that he should be allowed to leave the emergency room and go home after attempting suicide. The physician later killed himself. The psychiatrist was still bothered by the case 10 years later and believed he would have insisted on continued hospitalization had the man not been a doctor.

Warning Signs

The Southern Medical Journal report says suicide rates are higher among physicians who are divorced, widowed, or never married. The article also defines a high-risk physician as someone who is driven, competitive, compulsive, individualistic, ambitious, and often a graduate of a high-prestige school. It notes that the common characteristic of perfectionism may generate an unforgiving attitude in physicians when mistakes inevitably occur while they practice.

Dallas psychiatrist Byron L. Howard, MD, witnessed the unexpected loss of a patient causing a physician to fall into deep depression. He also cautions that physicians who have too few passions are susceptible to depression if their limited focuses become unstable.

"Physicians must have balance in their lives. Look at it as a three-legged stool. When you lose one leg, you have to work a little harder to stay balanced. You lose two, you have to work even harder. After losing the third, you inevitably fall down. Mental health is similar. You have to maintain a certain balance to remain standing."

In the Medscape interview, Dr. Silverman says stress unique to medical training and practice can contribute to mood disorders in physicians. He also says that while today's physicians tend to be more established in other facets of life, some have difficulty accepting that they could suffer from any form of illness.

"We have to realize that doctors are human beings, with the same foibles as their patients, vulnerable to the same stresses as everyone else. Doctors may be trained to cope with some stressors, but that's no guarantee that they won't get depressed," he said.

A June 18, 2003, article in the Journal of the American Medical Association by Dr. Hendin and several colleagues offers suggestions for how physicians can increase their awareness of suicide risks and improve their abilities to help others. (See "TSBME Changes Licensing Application Questions.") Primarily, physicians should establish a regular source of health care for themselves. They shouldn't feel hindered to seek help for mood disorders, substance abuse, or suicidal feelings. They should routinely screen all primary care patients for depression, which can help them recognize depression within themselves.

Additionally, it is important that physicians (even those in training) become more aware of how depression affects both their profession and society. Not only should they be able to recognize depression, but they also should educate medical students and residents to do the same. More research should be conducted on suicide topics such as physicians' risk, preventative methods, and what roles gender, ethnicity, and specialty play.

Finally, the stigma attached to mental illness must be eliminated. To address the situation, a more accepting and open attitude is needed in the medical profession when discussing it.

"Some progress has been made with regards to acceptance of mental illness," Dr. Khushalani said. "Yet even while the government talks about parity, their own program, Medicare, continues to cover physical conditions at a higher rate than mental problems. This discrepancy in the coverage alone displays an attitude that mental conditions are not taken as seriously as physical conditions -- a stance that affects the rest of the health care environment. Progress has been made, but the battle to eliminate the stigma surrounding mental conditions is far from being won completely."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629.

SIDEBAR

TSBME Changes Licensing Application Questions

Some psychiatric experts say that medicine has been slow to address physicians' mental health and that physicians are not encouraged to admit their vulnerabilities or ask for assistance. Physicians seeking help can encounter barriers such as discrimination in medical licensing and hospital privileges and lack of professional advancement.

That is the gist of an article in the June 18, 2003, issue of the Journal of the American Medical Association by Herbert Hendin, MD, medical director of the American Foundation for Suicide Prevention and professor of psychiatry at New York Medical Center, and several colleagues.

Currently, the Texas State Board of Medical Examiners (TSBME) requires physicians to submit records from each facility, physician, psychologist, sponsor, or other persons or entities involved in diagnosing and treating the disorder, condition, or addition if they disclose, within the parameters described on the application for a medical license, a mental condition or addiction problem that could impair their ability to practice.

TSBME maintains, in a form included with the application, that it does not wish to pry into the private affairs of applicants. However, the board argues that it is obligated to determine if an applicant is physically or mentally fit to practice medicine and that it must inquire into such matters to the extent necessary to make such determinations. The board does not seek disclosure of counseling or treatment for temporary or situational disorders of less than six months, unless an event affects the applicant's ability to practice medicine, even for a limited time.

TSBME Public Information Officer Jill Wiggins says the state's Medical Practice Act requires physicians applying for a license to "present proof satisfactory to the board that the applicant is of good professional character" and has not run afoul of the section that lists reasons for denial of a license or a disciplinary action. Violations listed "include the inability to practice medicine with reasonable skill and safety to patients because of illness; drunkenness; excessive use of drugs, narcotics, chemicals, or another substance; or a mental or physical condition."

Ms. Wiggins says that to prove "that an applicant has not violated this section of the statute, the board must inquire about an applicant's mental health history, as well as other relevant background information." She added that in February the board approved changes to the application after receiving complaints from several applicants. She says TSBME staff worked with the U.S. Department of Health and Human Services' Office for Civil Rights to develop the new questions.

Previously, applicants were asked if within the previous five years they had been diagnosed, treated, or admitted to a hospital or other facility for any of the following disorders or impairments:

A sexual disorder, including, but not limited to pedophilia, exhibitionism, voyeurism, frotteurism, or sexual sadism.

Applicants are now asked if within the previous five years they have:

Abused or have been addicted to alcohol or drugs or have been treated for alcohol or other substance dependency or addiction.

Been diagnosed with or treated for any of the following: schizophrenia or any other psychotic disorder; delusional disorder; bipolar or manic depressive mood disorder; major depression; antisocial personality disorder; or any other condition that significantly impaired the applicant's behavior, judgment, understanding, capacity to recognize reality, or ability to function in school, work, or other important life activities. (The board does not seek information regarding "situational counseling" such as stress counseling, domestic counseling, grief counseling, or counseling for eating or sleeping disorders.)

Been diagnosed with or treated for a physical or neurological condition that may currently impair the applicant's ability to practice medicine. If an applicant answers yes, he or she is asked to explain fully. As used in this question, "current" means recently enough so that the condition or impairment may have an ongoing impact.

Been diagnosed with or treated for pedophilia, exhibitionism, voyeurism, frotteurism, or sexual sadism.

Applicants who answer yes to either of the first two questions are asked if "the limitations caused by your mental health condition or substance abuse problem reduced or ameliorated because you receive ongoing treatment (with or without medication) or because you participate in a monitoring program?"

TSBME doesn't require applicants to submit records if they say they have been diagnosed with a mental condition but it does not impair their ability to practice, Ms. Wiggins says.

Critics argue that such policies by licensing boards can deter physicians from admitting they have a problem and seeking help.

Steven Miles, MD, a Minnesota geriatrician who is bipolar, wrote about his experience with the Minnesota licensing board. In an article in the Sept. 9, 1998, issue of JAMA , Dr. Miles explained why he and his psychiatrist refused to submit his psychiatric records to the board. Both felt the board had no business with such information because Dr. Miles was receiving treatment and there was no evidence his professional abilities were impaired. After a lengthy dispute, the licensing board changed its policy.

"Far from protecting the public, it is likely that abolishing confidentiality of a physician's personal health records would simply discourage troubled people, many with treatable disorders, from finding appropriate medical help and would hamper those trying to help them … such an impaired individual is far more likely to endanger patients," wrote Dr. Miles.

Psychiatrist Ashok I. Khushalani, MD, of Humble, agrees. Dr. Khushalani, who spoke at a TMA Physician Health and Rehabilitation Committee seminar on physician suicide in February, says there is "a stigma that any mental health condition is going to interfere with a physician's ability to function. The issue should be the functionality of physicians, not whether or not they have a mental health history."

Answered by a recording, the 24-hour hotline of the TMA Committee on Physician Health and Rehabilitation is the key to a completely confidential program that acts as an advocate for impaired physicians, rather than as a punitive agent.

Anyone concerned about a possibly impaired physician may call. While most callers use the hotline to report problems with addiction, the committee also can help physicians with impairments caused by psychiatric problems, cognitive disorders, aging, AIDS, or compulsive disorders.

All calls are confidential and are generally returned the same day. Calls are always returned at the convenience of the caller if a preferred time is specified.

Referring a colleague is not a betrayal of trust, committee members say. It is acting responsibly to contain and prevent the problem of impairment. A call could save a career and possibly a life.

Continuing medical education (CME) courses are available on the TMA Web site. Courses on caring for the caregiver, managing stress and burnout, establishing a peer assistance committee, and intervening for physicians who may be impaired are just a few of the courses that are available. You can earn ethics CME credit for completing them.

SIDEBAR

Danger Signs of Suicide

Risk Factors

Past history of attempted suicideBetween 20 and 50 percent of people who kill themselves have previously attempted suicide. Those who have made serious suicide attempts are at a much higher risk for actually taking their lives.

Psychiatric disorders

Depression

Personality disorders (especially borderline, antisocial)

Schizophrenia

Substance abuse, particularly when combined with depression

G enetic predispositionFamily history of suicide, depression, or other psychiatric illness.

NeurotransmittersA clear relationship has been demonstrated between low concentrations of the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in cerebrospinal fluid and an increased incidence of attempted and completed suicide in psychiatric patients.

ImpulsivityImpulsive individuals are more apt to act on suicidal impulses.

Demographics

Sex: Males are three to five times more likely to commit suicide than are females.

Age: Elderly Caucasian males have the highest suicide rates.

Suicide Crisis

A suicide crisis is a time-limited occurrence signaling immediate danger of suicide. Suicide risk, by contrast, is a broader term that includes the above risk factors as age and sex, psychiatric diagnosis, past suicide attempts, and traits like impulsivity. The signs of crisis are:

A precipitating eventA recent event that is particularly distressing such as loss of a loved one or career failure. Sometimes, the person's own behavior precipitates the event (e.g., a man's abusive behavior while drinking causes his wife to leave him).

Speech suggesting the individual is close to suicide. Such speech may be indirect. Be alert to such statements as "My family would be better off without me." Sometimes, those contemplating suicide talk as if they are saying goodbye or going away.

Actions ranging from buying a gun to suddenly putting one's affairs in order.

Deterioration in functioning at work or socially, increasing use of alcohol, other self-destructive behavior, loss of control, rage explosions.

Recognizing Depression

All of the danger signs are magnified in importance if the patient is depressed. Although most depressed people are not suicidal, most suicidal people are depressed. Serious depression can be manifested in obvious sadness, but often it is rather expressed as a loss of pleasure or withdrawal from activities that had been enjoyable.

Depression is present if at least five of these symptoms have been present nearly every day for at least two weeks:

Depressed mood;

Change in appetite or weight;

Change in sleeping patterns;

Speech and/or movement of unusual speed or slowness;

Loss of interest or pleasure in usual activities;

Decrease in sexual drive;

Fatigue or loss of energy;

Feelings of worthlessness, self-reproach, or guilt;

Diminished ability to think or concentrate, slowed thinking, or indecisiveness; or

Thoughts of death or suicide or wishes to be dead.

Suicide can be prevented. While some suicides occur without any outward warning, most do not. The most effective way to prevent suicide among loved ones is to learn how to recognize the signs of someone at risk, take those signs seriously, and know how to respond to them. The emotional crises that usually precede suicide are most often both recognizable and treatable.

The heat from the Texas summer was staggering. The sweltering temperatures were mild in comparison to the emotional inferno that would soon engulf me. On July 29, 1998, my life stood still and spun out of control at the same time.

Completing my shift as a volunteer on the crisis phone lines, I returned to my home and encountered an indescribable eeriness. My garage door was bolted and I had no way to get in the house. Walking around to the front of the house, I found another door bolted from the inside. The dogs were mysteriously silent and did not respond to my calls or ringing on the doorbell. As I continued walking around my house, I realized that my worst nightmare had come true. I looked into the windows of my living room and there was death staring at me. On the couch lay the lifeless body of my husband, with a needle in his arm attached to a now empty intravenous bag. An anesthesiologist, he had self-administered a lethal dose of anesthetic drugs. The very thing that provided his livelihood eventually took his life. Cause of death: Suicide.

How can a person who takes an oath of "do no harm" complete such a destructive act? The swirl of incongruent thoughts washed over me, drowning me, pounding me with a pain so intense I thought I would explode. How? Why? In the beat of a heart, the scope of my life was altered beyond my wildest dreams. The true-life nightmare bound me with the common threads of others, that my life had been changed forever. The question that most haunted me: "NOW WHAT?"

My lovely, peaceful home had instantaneously become a "crime scene." The paramedics were the first to arrive after what seemed like an eternity after I called 911 on my cell phone. They had to break down the door because we couldn't get in. Then the police, detectives, medical examiners, and others were wandering around, looking, and asking questions. I was devastated to the very core of my being. I did not know what was happening but suddenly began to understand that they treated a suicide case like a homicide. More devastation pummeled me.

What was going on here? I longed for a simple answer. Later I learned there are no simple answers to such complex situations. How does a person end his own life when it goes against a very basic survival instinct? Can the pain be so intense for so long that this act made sense to him? What was he thinking when he put a needle in his arm? What was he feeling?

My husband had mental health issues for years. But he refused treatment for these concerns for many reasons. The barriers to care for the health care professional are significant. There are vehicles in place to help the impaired physician. But these are often interpreted as solely substance abuse programs. The stigma surrounding mental illness is substantial. A prescription for disaster is the resistance to seek help for mental health concerns. The hesitancy may come from the concerns over licensure renewal, confidentiality, emotional deterioration, ego, and the significance of the stigma associated with mental health treatment. This was the void my husband walked in before his death. This is the place he stopped.

This is the legacy my family now carries with us. One of the things I searched for was some semblance of normalcy in my life. Sadly, I realized things would never look like they did previously. With time, I began to realize that everything did not revolve around this one part of my life, unless I let it. After a very long time, I came to realize I would be creating a "new normal" version for living. In order to shift my perception of events, I needed to look at them differently. I continued to restructure my life.

Over a period of time, something shifted within me. There grew a resurgence of energy within me. The swirl of incongruent thoughts bombarded my consciousness. I was striving for freedom. Freedom from the pain and the bondage it created. Freedom to live again. The message here is not about how my husband died. It is emphatically about how we, individually and collectively, choose to live our lives. No longer do I have the luxury of living a marginal life.

When the healing process led me to investigate the issue of physician depression and suicide, it became clear that there is a significant problem that needs to be addressed. It became equally clear that I would devote my life to shedding light on an unspoken topic. An ethical mandate suggests that the physician has a responsibility to be healthy mentally for his patients.

Wellness is the goal. The TMA Committee on Physician Health and Rehabilitation is doing some great work in the area of mental health wellness for the physician. The committee recently sponsored a retreat where they pulled together a consortium of experts, speakers, and other interested members to address the issue of physician depression and suicide. The consensus was that there continue to be major concerns to be addressed in the medical community on this topic.

The very traits that make physicians great at what they do can be the same ones that create distress. When perfectionism and drive collide with a competitive ego, they place the health care professional at high risk for burnout. When the physician is suffering from burnout or any other major stressor, clinical errors can become fatal mistakes. Self-neglect of the physician can lead to tragic consequences. Compassion fatigue can lead to the deterioration of family without understanding how it came to be so extreme.

When physicians begin to believe in confidentiality of their mental health concerns, the paradigm will begin to shift. The focus will be on wellness of the physician. The quality of care for patients will be maintained, and institutional policy changes will begin to transpire.

Out of honor to my husband and others who currently suffer from mental disorders or have ended their own lives, I have consciously chosen to move forward with my life. I believe, at some level, there must be a purpose to the destructive tides that have swept over my family and myself. We were knocked down, yes. We may have thought we were going to drown, and at moments, even wished we had. But we did not.

As a former psychotherapist and widow of a physician who died by suicide, Ginger Hilley offers a uniquely personal perspective on"Preserving Mental Health and Well Being Within the Health Care Community."Her keynote addresses and workshops offer strategies for living a more balanced life, enabling health care professionals to offer better patient care. She can be reached at (214) 363-5015 or by email at ginger@illuminainternational.com.